By Linda Komnick and Shelly Carolan
The dyad leadership model is widely used across healthcare, from oversight of medical practices to hospitals and health systems at the regional, service line or single site level. Dyads have obvious benefits. “You get two perspectives on all issues, whether clinical or operational,” says Patrice Weiss, M.D., a WittKieffer physician executive consultant who has served in various dyad roles throughout her career in academic medicine. In other words, two heads are usually better than one, especially when the two have complementary competencies and areas of expertise.
“That’s when the magic happens,” says Michael Michetti, J.D., COO of Everside Health and another veteran of dyad roles as an operations leader working with a physician leader. “The two individuals bring different skill sets and perspectives to make the sum greater than the parts.”
Dyad models are not new. Most sources point their origin to the Mayo Clinic in the early 1900s, with the recognition that there were clear benefits to having leadership derive from both practicing clinicians and career administrators. Historically, dyad models maintained a fairly straightforward division of labor: the physician focused on issues ranging from care quality and patient satisfaction to physician relations and compliance, while the non-physician tackled operations, revenue management, supply chain and other matters in which physician input was deemed nonessential. Shared duties might include strategic planning, budgeting, culture building, and performance management.
Over time dyad models have become much more nuanced as organizations figure out for themselves what works and what doesn’t. (Variations of dyad structures – or even triad models with a physician-nurse-administrator structure – have evolved as well.) With the trend toward value-based care and push to incorporate evidence-based medical insight into operational and strategic decision-making, dyad leadership now makes even more sense:
- Today’s increasingly matrixed organizations depend less on hierarchy and thus lend themselves to decision-making by dyads or even multidisciplinary teams.
- Independent medical groups, to effectively compete today, are adding operational leadership, thus blending the wisdom of career administrators with the status and technical expertise of physician leaders.
- New payment models under value-based care require leadership with the understanding of clinical care delivery through clinical protocols and heightened care standards.
- The need for embedded, operationalized quality metrics requires a unified approach from practitioners and non-physician leaders.
“If done correctly, dyads can really help an organization fine-tune and balance the demands of quality, safety, and physician engagement with operational excellence, metric goals and strategy alignment,” says Michetti. “Without dyads there are really two parallel structures, administrative operations and physician interests. Dyads transition situations that could be sources of tension into opportunities for synergy.”
The “if done correctly” that Michetti mentions is a major qualifier, of course. There are no guarantees that an individual dyad pairing – much less a dyad initiative throughout an organization – will succeed. We believe success is dependent upon two factors: promoting or hiring the right leaders into dyad roles; and creating optimal organizational structures and alignment that allow the dyad partners to “blend together” in a trusting, intuitive, symbiotic relationship.
Problems and Pitfalls
Detractors point to the fact that dyads can create inefficiencies (e.g., resource duplication), role confusion, communication gaps, and power struggles. We agree there exists the potential for dyads to struggle or even fail. Warning signs include:
- Lack of time commitment and investment by either or both partners. The dyad leaders must commit to regular, structured time together to build alignment and trust. From the physician’s perspective, there can be frustrating “role conflict” when they divide time between clinical practice and administrative duties.
- Insecurity among partners: Either leader may feel insecure about sharing leadership duties. Further, the non-physician might think: Why do they need me if a physician is capable of being an administrator? The physician partner may have sensitivities around becoming a part-time practitioner.
- Stubbornness or an unwillingness to learn. Carol Dweck’s well-known book Mindset expresses that professionals of all stripes will find fulfillment and success by maintaining an openness and fascination to learning and personal development. In the case of dyad pairs, if both partners aren’t committed to growth and development, problems will arise.
Leadership Competencies and Skills for Dyad Leadership
Most dyads work well, however. It is typically the partners and their shared relationship that determine success. The selection of the right individuals is critical to the eventual success or failure of dyad arrangements.
The basics of a strong dyad relationship include mutual respect, a shared sense of mission, aligned values, open communication, and complementary strengths and weaknesses. As with any partnership, an imbalance or fatal flaw in any of these factors undermines the union.
In speaking with dyad leaders across healthcare – within physician practices as well as hospital and health systems – we have tapped into other personality traits which are essential in both partners if the relationship is to thrive. They include:
- An embrace of servant leadership. As Bob Dylan sang, you’ve got to serve somebody. The sooner that leaders understand their interdependence with patients, colleagues (including their dyad partner) and the organization’s long-term strategic goals, the better off they”ll be.
- Comfort in a shared governance model. Related to the above, dyad executives must appreciate decision-making built on negotiation and consensus.
- High EQ. Having the ability to “hear” others and relate to them is critical. Physicians and healthcare administrators tend to be empathic by their callings, but having a full range of emotional tools at their disposal is important.
- Courage and humility. This includes an ability to make difficult decisions as well as to admit one is wrong or to cede authority at times to the dyad partner.
“The two partners must be equals and respect each other,” believes Anthony Aquilina, D.O., chief physician executive at WellSpan Health, who has also held dyad roles. “They must have a unified voice that speaks clearly and consistently to organizational values and goals.”
“You have to be willing to converse and meet with others outside of your initials” (i.e., M.D.), notes Dr. Weiss. “You can’t have a mindset that doctors are responsible for doctors and that administrators lead administrators.”
The dyad model is often illustrated with a Venn diagram showing minimal overlap between the two partners and predefined, rigid roles (graphic). Role definition and division of responsibilities – at least on paper – are important. However, dyad relationships – as with most marriages – must evolve as the two partners become attuned to each other’s needs, grow together, and transition into a less defined, more instinctive blend of shared responsibilities.
We view role rigidity as somewhat of a pre-pandemic remnant of dyad models. If COVID-19 taught healthcare anything about leadership, it’s that executives are most effective when they have the latitude to engage meaningfully with leadership peers and workplace colleagues to adapt to changing conditions and develop creative, confident solutions to everyday challenges. Dyads, too, can benefit from adaptability.
The key takeaway: Organizations must consider character and leadership competencies in selecting individuals to participate in dyads.
Creating the Right Organizational Infrastructure
In addition to selecting the right individuals, organizations instituting dyad models must set the stage for their success. Critical factors include:
- Organizational commitment. Dyad success requires organizational leadership to fully embrace the model, write Daniel Zismer and James Brueggemann of Essentia Health: “The dyad becomes a part of the cultural fabric of the organization; ‘it is how we do it here.’ “
- KPIs. Organizations should set key performance indicators and metrics (for quality, patient safety, finances, etc.) by which a dyad can measure its success. The KPIs also provide both partners with joint goals to align around.
- Regular review and continuous improvement of the partnership. We recommend that the two partners, regularly review their responsibilities and working relationship to progressively fine-tune it. What’s working and what’s not? What gray areas exist that produce confusion? Are we both growing in our capabilities and capacities as leaders?
- Coaching. The investment in a coach to assist the dyad pair in evaluating their work and relationship can pay dividends just as it would for an individual executive, lending objectivity to how the dyad is performing, patching up conflicts and focusing on collective improvement.
- Succession planning. Organizations which embrace dyads can integrate their key concepts into succession efforts, allowing executives time to anticipate and acclimate to an eventual paired leadership structure.
- Recruiting with dyad leadership in mind. Executive candidates can be evaluated not just for their individual expertise and potential but also for their ability to participate in a dyad should they be hired.
- Psychometric assessment. Related to the above, today’s leadership assessments can pinpoint qualities in executives such as communicativeness and cooperativeness which bode well for their ability to thrive in dyad roles.
Conclusion
The success of dyad leadership depends on how each arrangement is structured but also prominently on the specific individuals involved, the organizational context within which they operate, and how their relationship evolves. As the partners grow together over time, the whole can certainly be greater than the sum of the two parts.
